Appendix I
Worksheets and Checklists
Contents
Cognitive-Behavior Therapy Case Formulation Worksheet . . . . . . . 284
Automatic Thoughts Checklista . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Thought Change Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
Definitions of Cognitive Errorsa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Examining the Evidence for Automatic Thoughts Worksheeta . . . . . 289
Weekly Activity Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
Schema Inventorya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Examining the Evidence for Schemas Worksheeta . . . . . . . . . . . . . . 292
Well-Being Log: Building and Sustaining Well-Being . . . . . . . . . . . . 293
Safety Plan Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Cognitive-Behavior Therapy Supervision Checklist . . . . . . . . . . . . . 296
Appendix 1 is available as a free download in its entirety and in larger format on
the American Psychiatric Association Publishing Web site: https://www.appi.org/
wright.
a
Adapted with permission from Wright JH, Wright AS, Beck AT: Good Days
Ahead. Moraga, CA, Empower Interactive, 2016. Copyright © Empower Interactive, Inc. All rights reserved. Permission is granted for readers to use these items in
clinical practice.
283
284
Learning Cognitive-Behavior Therapy
Cognitive-Behavior Therapy
Case Formulation Worksheet
Patient Name:
Date:
Diagnoses/Symptoms:
Formative Influences:
Situational Issues:
Biological, Genetic, and Medical Factors:
Strengths/Assets:
Treatment Goals:
Event 1
Event 2
Event 3
Automatic Thoughts
Automatic Thoughts
Automatic Thoughts
Emotions
Emotions
Emotions
Behaviors
Behaviors
Behaviors
Schemas:
Working Hypothesis:
Treatment Plan:
Note.
Available at: https://www.appi.org/wright.
Appendix 1: Worksheets and Checklists
3
Automatic Thoughts Checklist
Instructions: Place a check mark beside each negative automatic thought
that you have had in the past 2 weeks.
I should be doing better in life.
He/she doesn’t understand me.
I’ve let him/her down.
I just can’t enjoy things anymore.
Why am I so weak?
I always keep messing things up.
My life’s going nowhere.
I can’t handle it.
I’m failing.
It’s too much for me.
I don’t have much of a future.
Things are out of control.
I feel like giving up.
Something bad is sure to happen.
There must be something wrong with me.
Note.
Available at: https://www.appi.org/wright.
Situation
Automatic
thought(s)
a. Describe event leading
to emotion or
b. Stream of thoughts
leading to emotion or
c. Physiological
sensations.
a. Write automatic
thought(s) that
preceded emotion(s).
b. Rate belief in
automatic thought(s),
0%–100%.
286
Thought Change Record
Emotion(s)
Rational response
Outcome
a. Specify sad, anxious,
angry, etc.
b. Rate degree of
emotion, 1%–100%.
a. Identify cognitive
errors.
b. Write rational
response to automatic
thought(s).
c. Rate belief in rational
response, 0%–100%.
a. Specify and rate
subsequent
emotion(s), 0%–100%.
b. Describe changes in
behavior.
Learning Cognitive-Behavior Therapy
Source. Adapted from Beck AT, Rush AJ, Shaw BF, et al.: Cognitive Therapy of Depression. New York, Guilford, 1979, pp. 164–165. Reprinted with
permission of Guilford Press. Available at: https://www.appi.org/wright.
Appendix 1: Worksheets and Checklists
287
Definitions of Cognitive Errors
Selective abstraction (sometimes called ignoring the evidence or the
mental filter) A conclusion is drawn after looking at only a small portion
of the available information. Salient data are screened out or ignored in
order to confirm the person’s biased view of the situation.
Example: A depressed man with low self-esteem doesn’t receive a holiday card from an old friend. He thinks, “I’m losing all my friends; nobody cares about me anymore.” He is ignoring the evidence that he
has received a number of other cards, his old friend has sent him a
card every year for the past 15 years, his friend has been busy this past
year with a move and a new job, and he still has good relationships
with other friends.
Arbitrary inference Coming to a conclusion in the face of contradictory
evidence or in the absence of evidence.
Example: A woman with fear of elevators is asked to predict the
chances that an elevator will fall if she rides in it. She replies that the
chances are 10% or more that the elevator will fall to the ground and
she will be injured. Many people have tried to convince her that the
chances of a catastrophic elevator accident are negligible.
Overgeneralization A conclusion is made about one or more isolated incidents and then is extended illogically to cover broad areas of functioning.
Example: A depressed college student gets a B on a test. He considers
this unsatisfactory. He overgeneralizes when he has these automatic
thoughts: “I’m in trouble in this class....I’m falling short everywhere in
my life....I can’t do anything right.”
Magnification and minimization The significance of an attribute, event,
or sensation is exaggerated or minimized.
Example: A woman with panic disorder starts to feel light-headed during the onset of a panic attack. She thinks, “I’ll faint. . . . I might have a
heart attack or a stroke.”
Personalization External events are related to oneself when there is little evidence for doing so. Excessive responsibility or blame is taken for
negative events.
288
Learning Cognitive-Behavior Therapy
Example: There has been an economic downturn, and a previously
successful business is now struggling to meet the annual budget. Layoffs are being considered. A host of factors have led to the budget crisis, but one of the managers thinks, “It’s all my fault. . . . I should have
seen this coming and done something about it. . . . I’ve failed everyone in
the company.”
Absolutistic thinking (also called all-or-nothing thinking) Judgments
about oneself, personal experiences, or others are placed into one of two
categories: all bad or all good; total failure or complete success; completely flawed or absolutely perfect.
Example: Dan, a man with depression, compares himself with Ed, a
friend who appears to have a good marriage and whose children are doing well in school. Although the friend has a fair amount of domestic
happiness, his life is far from ideal. Ed has troubles at work, financial
strains, and physical ailments, among other difficulties. Dan is engaging in
absolutistic thinking when he tells himself, “Ed has everything going for
him....I have nothing.”
Note. Available at: https://www.appi.org/wright.
289
Appendix 1: Worksheets and Checklists
Examining the Evidence for
Automatic Thoughts Worksheet
Instructions:
1. Identify a negative or troubling automatic thought.
2. Then list all the evidence that you can find that either supports (“evidence
for”) or disproves (“evidence against”) the automatic thought.
3. After trying to find cognitive errors in the “evidence for” column, you can
write revised or alternative thoughts at the bottom of the page.
Automatic thought:
Evidence for automatic thought:
Evidence against automatic thought:
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
Cognitive errors:
Alternative thoughts:
Note. Available at: https://www.appi.org/wright.
290
Weekly Activity Schedule
Instructions: Write down your activities for each hour and then rate them on a scale of 0–10 for mastery (m) or degree of accomplishment and for pleasure (p) or amount of enjoyment you experienced. A rating of 0 would mean that you had no sense of
mastery or pleasure. A rating of 10 would mean that you experienced maximum mastery or pleasure.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
8:00 A.M.
9:00 A.M.
10:00 A.M.
12:00 P.M.
1:00 P.M.
2:00 P.M.
3:00 P.M.
4:00 P.M.
5:00 P.M.
6:00 P.M.
7:00 P.M.
8:00 P.M.
9:00 P.M.
Note. Available at: https://www.appi.org/wright.
Learning Cognitive-Behavior Therapy
11:00 A.M.
291
Appendix 1: Worksheets and Checklists
Schema Inventory
Instructions: Use this checklist to search for possible underlying rules of
thinking. Place a check mark beside each schema that you think you may have.
Healthy Schemas
No matter what happens, I can
manage somehow.
If I work hard at something, I can
master it.
I’m a survivor.
Others trust me.
I’m a solid person.
People respect me.
They can knock me down, but
they can’t knock me out.
I care about other people.
If I prepare in advance, I usually
do better.
I deserve to be respected.
I like to be challenged.
There’s not much that can
scare me.
I’m intelligent.
I can figure things out.
I’m friendly.
I can handle stress.
The tougher the problem, the
tougher I become.
I can learn from my mistakes and
be a better person.
I’m a good spouse (and/or
parent, child, friend, lover).
Everything will work out all
right.
Maladaptive Schemas
I must be perfect to be accepted.
If I choose to do something, I
must succeed.
I’m stupid.
Without a woman (man), I’m
nothing.
I’m a fake.
Never show weakness.
I’m unlovable.
If I make one mistake, I’ll lose
everything.
I’ll never be comfortable around
others.
I can never finish anything.
No matter what I do, I won’t
succeed.
The world is too frightening
for me.
Others can’t be trusted.
I must always be in control.
I’m unattractive.
Never show your emotions.
Other people will take advantage
of me.
I’m lazy.
If people really knew me, they
wouldn’t like me.
To be accepted, I must always
please others.
Note. Available at: https://www.appi.org/wright.
292
Learning Cognitive-Behavior Therapy
Examining the Evidence for
Schemas Worksheet
Instructions:
1.
Identify a negative or maladaptive schema that you would like to change.
Write it down on this form.
2.
Write down any evidence that either supports or disproves this schema.
3.
Look for cognitive errors in the evidence for the maladaptive schema.
4.
Finally, note your ideas for changing the schema and your plans for
putting these ideas into action.
Schema I want to change:
Evidence for this schema:
Evidence against this schema:
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
Cognitive errors:
Now that I’ve examined the evidence, my degree of belief in the schema
is: Ideas I have for modifications to this schema:
Actions I will take now to change my schema and act in a healthier way:
Note. Available at: https://www.appi.org/wright.
Situation
Experiences and feelings of
well-being
Interfering thoughts
and/or behaviors
Observer
293
Note. Available at: https://www.appi.org/wright.
Intensity (0–100)
Appendix 1: Worksheets and Checklists
Well-Being Log: Building and Sustaining Well-Being
294
Learning Cognitive-Behavior Therapy
Safety Plan Worksheet
Step 1: Warning signs:
1.
2.
3.
Step 2: Internal coping strategies—
Things I can do to take my mind off my problems
without contacting another person:
1.
2.
3.
Step 3: People and social settings that provide distraction:
1.
Name
Phone
2.
Name
Phone
3.
Place
4.
Place
Step 4: People whom I can ask for help:
1.
Name
Phone
2.
Name
Phone
3.
Name
Phone
Step 5: Professionals or agencies I can contact during a crisis:
1.
Clinician/Agency Name_
Phone
Clinician
Phone
Clinician
Pager or Emergency Contact #
2.
Clinician/Agency Name
Pager or Emergency Contact #
3.
Local
Emergency
Emergency
Department
Emergency Department Phone
4.
Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255)
5.
Other:
Note. Available at: https://www.appi.org/wright.
Department
Address
295
Appendix 1: Worksheets and Checklists
Step 6: Making the environment safe:
1.
2.
3.
Step 7: Reasons for living—The things that are most important to me
and worth living for are:
1.
4.
2.
5.
3.
6.
Source. Reproduced with permission (© 2008, 2012, 2016 Barbara Stanley, Ph.D., and
Gregory K. Brown, Ph.D.). To register to use this form and for additional training
resources, go to: www.suicidesafetyplan.com.
Note. Available at: https://www.appi.org/wright.
296
Learning Cognitive-Behavior Therapy
Cognitive-Behavior Therapy Supervision Checklista
Therapist
Supervisor
Date
Instructions: Use this checklist to monitor and evaluate competencies in CBT.
Listed in Part A are competencies that should typically be demonstrated in each
session. Part B contains competencies that may be demonstrated over a course
of therapy or therapies. The checklist is not intended for evaluation of
performance in first or last sessions.
Part A: Competencies that should typically be demonstrated in each session
Competency
N/A
1. Maintains
collaborative
empirical alliance
Needs
Did not
Superior Satisfactory improvement attempt or
2. Expresses appropriate
empathy, genuineness
3. Demonstrates
accurate
understanding
4. Maintains
appropriate
professionalism and
boundaries
5. Elicits and gives
appropriate
feedback
6. Demonstrates
knowledge of CBT
model
7. Demonstrates ability
to use guided
discovery
8. Effectively sets
agenda and
structures session
9. Reviews and assigns
useful homework
10. Identifies automatic
thoughts and/or
beliefs (schemas)
11. Modifies automatic
thoughts and/or
beliefs (schemas)
Note. Available at: https://www.appi.org/wright.
Appendix 1: Worksheets and Checklists
Competency
N/A
12. Utilizes behavioral
intervention or
assists patient with
problem solving
297
Needs
Did not
Superior Satisfactory improvement attempt or
13. Applies CBT
methods in flexible
manner that meets
needs of patient
Part B: Competencies that may be demonstrated over a course of therapy
or therapies
Needs
Did not
Competency
Superior Satisfactory improvement attempt or
N/A
1. Sets goals and plans
treatment based on
CBT formulation
2. Educates patient about
CBT model and/or
therapy interventions
3. Demonstrates ability to
use thought record or
other structured
method of responding
to dysfunctional
cognitions
4. Can utilize activity
or pleasant events
scheduling
5. Can utilize exposure
and response
prevention or graded
task assignment
6. Can utilize
relaxation and/or
stress management
techniques
7. Can utilize CBT
relapse prevention
methods
Comments:
a
Checklist developed by Donna Sudak, M.D., Jesse H. Wright, M.D., Ph.D., David
Bienenfeld, M.D., and Judith Beck, Ph.D., 2001.
Note. Available at: https://www.appi.org/wright.